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Designing and Implementing Pay-for-Performance Programs: Ongoing Challenges

Designing and Implementing Pay-for-Performance Programs: Ongoing Challenges. Gary J. Young, J.D., Ph.D. Boston University Presentation for AHRQ Annual Meeting Session on How Pay-for-Performance Fits with a Value Agenda September 28, 2007

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Designing and Implementing Pay-for-Performance Programs: Ongoing Challenges

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  1. Designing and ImplementingPay-for-Performance Programs: Ongoing Challenges Gary J. Young, J.D., Ph.D. Boston University Presentation for AHRQ Annual Meeting Session on How Pay-for-Performance Fits with a Value Agenda September 28, 2007 Financial support from Agency for Healthcare Research and Quality; Robert Wood Johnson Foundation

  2. P4P: Will it Work? Recent evidence points to modest gains from P4P in terms of provider adherence. Selected Findings: • Rosenthal et al. (2006) Relative increase of 3.6 percentage points for cervical cancer screening • Levin-Scherz et al. (2006) Relative increase of 2-19 percentage points for diabetes measures • Lindenauer et a. (2007) CMS Premier demonstration: Relative increase of 2.6 percentage points for AMI measures; 3.4 points for pneumonia measures; 4.1 points for heart failure measures. • Young et al. (2007) Absolute increase of 7 percentage points for diabetes measure (e.g., eye exam)

  3. Key Challenges • Provider Engagement • Unit of Accountability • Quality Measures • Provider Capability • Incentive Structure • Data Systems and Measurement • Unintended Consequences

  4. Supporting Research • 7 Demonstration Sites – Rewarding Results • Surveys of Physicians (over 4000 surveyed; approximately 1500 responses) • Interviews with over 60 Senior Managers • of Physician Organizations • Focus Groups with Providers and Payers • Site Visits to Provider Organizations • Findings of Other Researchers

  5. Provider Engagement • Physicians appear comfortable with the concept of P4P. --Strong preference for incentives linked to quality vs. utilization or productivity

  6. Survey Results

  7. Survey Results

  8. Provider Engagement • Physicians do not appear to have a strong understanding of the P4P programs in which they participate. Conventional forms of communicating w/ providers appear inadequate (very Low physician survey scores regarding understanding of programs). • Many physicians appear to feel disenfranchised. Physician involvement in program design can help secure buy-in (e.g., selection/modification of measures).

  9. Unit of Accountability • Sponsors face difficult choices and possible tradeoffs between selecting individuals versus organizations. -- systems engineering vs. physician initiative -- stimulating investment in QI infrastructure vs. enhancing engagement of front-line providers.

  10. Quality Measures • Physicians generally comfortable with standardized measures such as HEDIS and HQA. --Outcomes vs. Process Measures --Specialists and Non-Acute Care Settings

  11. Provider Capability • Providers reveal anxiety about capabilities to perform well on quality measures. --Hospitals with well developed QI infrastructure appeared to have a distinct advantage in BCBSM P4P • With limited provider capability, one-time performance gains may be common. --In some situations, learning goals should possibly precede performance goals

  12. Incentive Structure • Both program sponsors and providers are divided on many issues regarding incentive structure. --Attainment vs. Improvement --Bonus only vs. Penalties (e.g., withholds)

  13. Data Systems and Measurement • Providers have strong concerns about data reliability and validity. --Claims vs. Charts (appeals process/reserve fund) -- Small Numbers (composite scores multi-payer initiatives)

  14. Unintended Consequences • Physician surveys reveal no major concerns about UC. --Some studies outside healthcare point to negative impact on innovation. -- P4P in safety net settings may pose unique risks.

  15. Concluding Comments • P4P can lead to gains in clinical quality, but the magnitude of the gains may be quite modest and time-limited, particularly without substantial improvements in provider infrastructure for quality measurement and improvement. • Physicians do appear comfortable with P4P as a concept, but have certain concerns with the way P4P programs have been designed and implemented. • Program sponsors face many daunting challenges in designing and implementing programs.

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